NCLEX Questions (Week 2)

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

Metabolic acidosis

The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?

"I should use disposable plates, forks, and knives."

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching?

"I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

A child is diagnosed with bacterial conjunctivitis, and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse would make which response to the parent?

"The child should be kept home until the antibiotic eye drops have been administered for 24 hours."

The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis?

- Hematocrit (Hct) 30% - Hemoglobin (Hgb) 8.8 g/dL - Decreased mean corpuscular volume (MCV) 66 fL

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)?

- Perform hand hygiene after removal of PPE. - Perform hand hygiene before donning any PPE. - When removing PPE, always remove gloves first. - Protective eyewear and face shield are indicated if there is risk of splatter.

The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?

1,000 calories

The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present?

5000 mm3 (5 × 109/L)

The correctional nurse is assisting in developing an in-service for new correctional nurses. The nurse would suggest to include which at-risk health disparities that occur in the prisoner population, when compared to the general population?

Asthma--Hepatitis C--Hypertension--Drug dependence

A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge?

Avoid activities that involve pulling or pushing--Do not lift objects weighing more than 5 pounds--Do not climb stairs until after the follow-up appointment with the surgeon

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

Droplet

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client?

Eat a nutritious diet with adequate protein--Use a pressure relief pad while in a wheelchair--Check the bottom sheet for wetness and wrinkles

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care?

Frequent assessment of vital signs--Coughing and deep breathing exercises--Pain monitoring and medications to relieve pain

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse use during the bathing of this client?

Gown--gloves

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period?

Grief--Anxiety--Altered body image

The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result would indicate to the nurse that the surgery might be postponed?

Hemoglobin, 8.4 g/dL

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse would be most concerned with the client who uses which CAMs?

Homeopathy--Herbal supplements

The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms would the nurse determine to be indicative of a potential complication?

Increasing restlessness--Unrelieved pain despite receiving analgesics

The nurse reinforces postoperative liver biopsy instructions to a client. Which would the nurse tell the client?

Lie on the right side for 2 hours.

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

Metabolic alkalosis

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How would the nurse determine that the restraints are not too constrictive?

Place two fingers under the restraint to determine snugness.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat foods from which nutrient categories to promote wound healing?

Protein--Vitamin C

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

Remove metallic objects from the client.

Which fluids are identified as insensible fluid losses?

Sweat--Sputum

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives the report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide, penicillin, and ibuprofen. He has received ibuprofen twice in the last 24 hours. He is oriented and cooperative. Which score would the client receive based on the fall risk tool?

9 total points (moderate risk)